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Human Back Pain PowerPoint Presentation

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On : Mar 14, 2014

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  • Slide 1 - Adolescent Back Pain(Quit yer whinin’…) Amy K Evans, PGY1 Adolescent Medicine National Naval Medical Center August 2005
  • Slide 2 - Case Presentation CC: College physical HPI: 19yo WM presents for routine physical. No current concerns. Oh wait, actually my back hurts. Past 4-6mo. Pain low mid-back just above belt level, band-like distribution but no radiation above or below. Occurs in AM after exercising day prior; gone by noon. Does not use heat, ice, or meds. No pain in buttocks or legs. No reported numbness/weakness. No specific hx trauma. PMHx: None Meds: None
  • Slide 3 - Case Presentation HEADSS: Younger brother, good family relationships Soph at Miami of Ohio Excellent grades Government major Basketball, LAX as club sports Girlfriend x9mo, no SA Occasional EtOH, no smoking, no drug use
  • Slide 4 - Case Presentation Physical Exam: AFVSS; Ht 75%; Wt 75% Exam unremarkable Back: symmetric, no scoliosis, no erythema/edema, no tenderness to palpation, no paraspinal spasm, FROM flex/ex Positive lumbar hyperextension test bilat LE: decreased hamstring flexibility (1/10), normal strength & sensation, FROM hips, knees, ankles
  • Slide 5 - Back Pain in Pediatrics Uncommon CC, but common occurrence 7% of 12yo with >1 episode LBP 50% of 18yo F, 50% of 20yo M Most not definitively diagnosed Most benign etiologies ~Half of episodes musculoskeletal (ER) 10% infectious, 13% idiopathic, 13% SCD Remember, backpacks <15-20% of weight!
  • Slide 6 - Back Pain in Pediatrics:Differential Diagnosis
  • Slide 7 - Red Flags! Infectious, Neoplastic, Rheumatologic Acute trauma Night pain Worsening pain Systemic symptoms Neuro symptoms Hx CA/TB exposure Severe disability Young age (<4yo)
  • Slide 8 - RedHawk’s Films
  • Slide 9 - What does he have? Spondylolysis: Defect (separation) in pars interarticularis Spondylolisthesis: Anterior slippage of vertebral body over next lowest body
  • Slide 10 - Spondylolysis Found in 7-8% of general population Found in 5% by age 6 Males>Females (2:1) Females more likely to progress to spondylolisthesis White>African-American Most commonly at L5 (90%; 80% bilat) Often asymptomatic/incidental finding
  • Slide 11 - Who is at risk? Genetic predisposition Alaskans 40% adults Eskimos 54% adults Family history Spina bifida occulta? Athletes with repetitive hyperextension Gymnasts Divers Football offensive linemen Pole vaulters Weight lifters Wrestlers LAXers!
  • Slide 12 - Spondylolysis:Presentation Low back pain, typically at belt line Insidious onset, may increase with activity Rarely radiating Commonly in preadolescent growth spurt Usually no hx trauma Usually no neuro deficits
  • Slide 13 - Spondylolysis:Physical Findings Hyperlordosis Vertical sacrum Iliac crests high, ribs look low “Short” torso +/- “Step-off” at L5 +/- Facet joint tenderness Hamstring spasm – classic in adolescents! Phalen-Dickson sign (hip-flexed, knee-flexed gait)
  • Slide 14 - Lumbar Hyperextension Test
  • Slide 15 - Spondylolysis:Diagnosis X-Ray: First-line! SPECT: If films negative but H&P suggestive CT: If SPECT positive but dx inconsistent Bone Scan: If suspected acute pars fx MRI: If neuro involvement
  • Slide 16 - Plain Films Oblique X-ray: “Collar” of Scottie dog Greyhound sign PA/Lat X-ray: Contralateral sclerosis
  • Slide 17 - Scottie Dog
  • Slide 18 - Spondylolysis:Proposed Classification Type I: Dysplastic Type II: Developmental Type III: Traumatic A: Acute B: Chronic Stress reaction Stress fracture Type IV: Pathologic
  • Slide 19 - Treatment Depends on SLIPPAGE and SYMPTOMS and SKELETAL MATURITY Spondylolysis and Grade I Spondylolisthesis (<25%): Regular activity. PT. Annual x-rays. Grade II (25-50%): Activity restriction. PT. Re-eval 3-6mo. Grade III (50-75%) - Grade IV (>75%): Surgery for >50% slippage, or >30% in skeletally immature pts; progressive slippage, persistent pain, or neurological symptoms.
  • Slide 20 - Conservative Treatment Activity restriction NSAIDs Physical therapy Abdominal/back strengthening Hamstring stretching Bracing/Casting Symptomatic Acute pars fx www.Narang.com
  • Slide 21 - ppt slide no 21 content not found
  • Slide 22 - Conclusions Don’t dismiss a patient with back pain Rule out Red Flags Full ortho & neuro exams Start with plain films Spondylolysis is the most commonly diagnosed organic cause of back pain, and is easily treated!
  • Slide 23 - References Behrman RE & Kliegman R. Nelson Essentials of Pediatrics. Philadelphia: WB Saunders, 1990. Hay WW, Hayward AR, Levin MJ, & Sondheimer JM. Currents Pediatric Diagnosis and Treatment, 16th ed. New York: Lange, 2003. Wiesel SW & Delahay JH. Essentials of Orthopaedic Surgery, 2nd ed. Philadelphia: WB Saunders, 1997. DeWolfe C. Back pain. Pediatrics in Review 2002;23(6):221. Nigrovic PA & Wilking AP. Overview of the causes of back pain in children and adolescents. UpToDate Online 13.2 April 2005. Nigrovic PA & Wilking AP. Evaluation of the child with back pain. UpToDate Online 13.2 April 2005. Smith JA & Hu SS. Management of spondylolysis and spondylolisthesis in the pediatric and adolescent population. Orthop Clin North Am 1999;30(3):487-499. Herman MJ & Pizzutillo PD. Spondylolysis and spondylolisthesis in the child and adolescent: a new classification. Clin Orthop 2005;434:46-54.
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